Acronyms
RM
What is Referral Management?
John, a TRICARE beneficiary, is living with Type 2 Diabetes and is working to manage his weight. What Clinical Operations program team will best support him?
What are Population Health and Disease Management?
Two types of beneficiaries
Who are Sponsors and Family?
Concurrent Review
Ensures beneficiaries receive _____ care
What is Quality Care?
UM
What is Utilization Management?
Peter has recently lost his brother in a tragic accident. Since then, he's been struggling to cope with the grief and has developed a drug dependence. Which Clinical Operations program would provide support?
What is Mental Health?
9 categories of beneficiaries
ADSM
National Guard/Reserve
Retired Service Members
Medal of Honor Recipients
Spouses and certain former spouses
Children
Survivors
Beneficiaries eligible for TRICARE and Medicare
Performs medical necessity reviews and appeals for some medical procedures
What is eviCore?
the three focus areas for CQM
What are:
1 Potential Quality Issue (PQI)
2. Potential Safety Issue (PSI)
3. Quality and Value Improvement Initiative (Studies and Quality Improvement Projects)
CQM
What is Clinical Quality Management?
Maria underwent surgery to remove her appendix at a network healthcare facility. At her follow-up appointment, she mentions to the nurse that she has been experiencing severe pain and signs of infection at the surgical site and reveals that she was not given proper postoperative care instructions or any information about what to do if complications arose. Her pain medication prescription was written incorrectly, leading her to miss doses during her recovery. The beneficiary reports this concern to TriWest. What Clinical Operations program is involved in this process?
What is Clinical Quality Management?
8 demographics that impact beneficiary eligibility for TRICARE plans
Age
Children until they age out or lose eligibility for other reasons
Survivors
Location
Activated National Guard and Reserve members called or ordered to active-duty service for more than 30 days in a row
Medal of Honor recipients and their families
Qualified Former Spouses
Qualified adult children up to age 21 or 23 if enrolled in college
4 types of utilization review
What are Prospective Review, Concurrent Review, Retrospective Review, and Appeals/Reconsiderations
Performs outreach to providers and facilities, manages incoming and outgoing correspondence, and creates cases in Medical Management System
Who is a Clinical Quality Specialist?
CM
What is Case Management?
Sarah has just received a serious illness diagnosis. Sarah's provider is contacting the call center to inquire about available support and resources to help Sarah navigate this challenging. Which Clinical Operations program can best support Sarah?
What is Case Management?
Mandatory TRICARE plan for Active Duty Service Members
TRICARE PRIME
3 criteria for review
What are TRICARE Manuals, Internal Policy and InterQual?
Includes current employees, new employees, contractors, consultants, direct-hire temporary employees and agency temporary employees that come into direct/indirect contact with the patients or providers concerning their health care
Who are workforce members?
PH & DM
What are Population Health & Disease Management?
System where a beneficiary can locate an authorization or referral?
What is the Beneficiary Portal?
Exceptions in which TRICARE does NOT pay after OHI
Medicaid
TRICARE Supplemental Insurance
State Victims of Crime Compensation Programs
Other Federal Government Programs identified by the Director of the Defense Health Agency
TriWest utilizes ___________ for external Peer review
Who is Medical Review Institute of America (MRIoA)
A clinical or system variance warranting further review and investigation for determination of the presence of an actual Quality Issue (QI).
What is a Potential Quality Issue (PQI)?